ACC Form

ACC 45 Form- Personal details

Please complete patient form as below.
Patient Name*

First NameLast Name
Date of Birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Gender*
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Patient E-Mail*
example@gmail.com
What is your ethnic background? This information is collected for statistical reasons only.*

NZ European/PakehaOther EuropeanNZ MaoriCook Island MaoriTonganNiueanFijianOther Pacific IslandSouthEast AsianIndianOther AsianChineseKoreanSamoanTokelauanAfricanMiddle EasternLatin American/HispanicDecline to Answer
Accident & Employment Details

You can provide the information as best as you can to the following questions on this form.
When did the accident happen?

DayMonthYear
Date
At what time?

:HourMinutesAM/PM Option
Accident Scene (e.g home, place of work, road)*
Accident Location (e.g Auckland)*
Did the accident happen in NZ?*

YesNo
What were you doing? - what happened - how was the injury caused?(e.g lifting box, strained lower back)*
Did the accident involve a moving vehicle on a public road?*

YesNo
If sporting injury name sport: (e.g soccer)
Occupation*
Please tick those that apply:*

I work part-time or full time job.I own/part-own the business in which I workI am self employedI am not employed
What type of work do you do?*

Sedentary(brief standing and walking)Light(mainly standing and walking)Medium(often lift 5kg plus)Heavy(often lift 9kg plus)Very Heavy(often lift 22kg plus)
Did the injury happen at work?*

YesNo
If Yes, Employer Name:
Employer Address:
Patient Authorisation and Declaration

I have read and understood the important Patient Information and Patient Declaration
I have provided the information on this form as best as I can and declare that this information is true and correct as I understood so far for claiming ACC. And I agree that I am giving permission to my provider to claim ACC based on the information as stated as above. If ACC declines the claim, I agree that I am liable to pay the full amount of treatment cost on the visits as I have visited.
Client Signature*

Clear
By signing you agree to the conditions stated above
Todays Date*

DayMonthYear
Should be Empty:

ACC 45 Form- Personal details

Accident & Employment Details

Patient Authorisation and Declaration